There are so many things I wish I could share with everyone about understanding our healthcare system. However, here are a few basics that should help get you thinking.
ONE: Checking in/out of-network status when you move somewhere
How close is the hospital, are there others closer?
Is my insurance in-network with only certain facilities verses providers?
Is my insurance covered by certain care types (example Urgent Care vs Emergency Departments)?
Most people, when moving to a new area, buying a home, check two things: School district and property tax. So, why not check local hospitals/Emergency Departments (EDs), offsite EDs, and Urgent Cares (UC) for network status with current insurance?
Even if you do not have children, you still check the school district, because at some time you may either have children, or you may want to sell your house and the district will be important to home buyers. So, why not do our personal homework on healthcare? Yes, it's more specific to the individual, their job, their insurance, but it's not any less important to research.
Now I will note that with each year there have been advances in laws to help protect the individual from out-of-network (OON) billing, but it’s not perfect, nor is it clear to the average US citizen.
TWO: Checking procedures before treatment
Unless you are in a life or limb threatening situation, check what you are getting treated. Whether it be an urgent care or ED visit, vs and inpatient/outpatient treatment.
I see far too many times, people are pleased with their level of care by a facility or provider, until they get a bill and are surprised by what they were treated/checked for.
In any situation, ask.
Ask the medical staff, or even call your insurance about coverage. Yes, you can call your insurance and ask for coverage information before you get that treatment. Be proactive so you understand your coverage before you are in a situation when you need it.
THREE: 2 bills - supplies and services
If you are visiting a hospital, Emergency Department (ED), Urgent Care (UC), surgery and scans, basically anything outside you PCP visit, you are likely to get two bills (at minimum!)
The bill most people receive first, or even know about prior to their visit or before leaving a facility, is the facility bill. However, the other bill(s) are that of the actual provider(s) that treated you, and/or oversaw the provider treating you.
Parts and labor = supplies and services. There are always two things in facility-based treatments. The industry sometimes merges these two bill types into a single invoice (think of any bill from your automotive repair shop...parts used and people labor). It is more likely that you will get two separate bills. This is because it can be easily defined on what you “used” while you were being treatment: this bed, that gauze, those injections, etc. It is much more difficult to translate the pricing of the provider’s actionable care into a bill. This is the real calculated artwork and necessary skill set of coding.
FOUR: Balanced Billing
The hot topic that has everyone in the healthcare industry leaning a keen ear to learn even the slightest hint of legislative change.
A simplistic question; should people be billed for provider and specialty out-of-network (OON) services if the facility they sought treatment at was in-network (INN) with their insurance? (dependency on our #1 in checking network status).
I want to switch up this question a bit, not to detract from the importance, but to provide some counter-thoughts. Are there ever situations where a patient should be responsible for paying a bill regardless of network status? Digging deeper, how is that responsibility split/shared between the following players:
The individual patient utilizing the benefits of the plan.
The employer who negotiated and purchased the plan.
The provider or facility who determined INN/OON status while pursing negotiations towards INN status.
Or the payor that defined which services would be covered contractually between the employer, payor, provider, or any unique service line.
Who wins? Is there even a winner? If the patient wins, does it impact the accessibility of healthcare, or does it change certain service lines? I personally am not sure, as this spiderweb was not created in a day. Clearly, it is a bit more complicated that we make it out to seem in the news. This is why I am fine that legislation around a final decision has taken such a long time. The industry is changing, and this slow moving 100+ year old tortoise needs time to adjust and pivot.
FIVE: The patient bill may not occur for 6 months to a year
This is the exception to the standard, not the standard.
There is a hidden world that the average person knows nothing about….this is revenue cycle. This is what occurs after you leave your treatment.
Behind the point of service application of providers and clinical staff treating you is a hidden army of technology and people orchestrating the continued translation of your visit into codes, interfaces, prices, transmissions, and bills. It takes time, and sometimes it does not always process cleanly, without error.
It is unrealistic to think that every single patient encounter moves seamlessly through the revenue cycle. All things are faulty at their weakest point and the same rule holds true for healthcare. We want to fix the errors, the sluggishness in our processes, just as much as you want your bill timely.
I want to exposing the hidden world of healthcare. It is all out there, a conversation or a web search away. I want to share it with you.